Tuesday, June 30, 2009

Regular readers know that I believe in administrative, as well as clinical, transparency in our hospital. I have trouble understanding why this is unusual, but I know that it is. I just can't imagine trying to solve the problems of an organization and having a common sense of purpose and direction unless everybody is aware of what's going on.

Back in March, I promised I would report back to you on budget and financial issues in June. Here we go:

First, here are the details of our progress in the current fiscal year. As a result of the steps we all took together, we expect to break even for this year. What could have been a $20 million loss has been eliminated. With your help, what could have been 600 layoffs was reduced to 70 layoffs. With your extra help, we were able to insulate our lower wage staff members from what could have been particularly bad news. BIDMC has received national acclaim for our approach to solving these budget problems, and our story has caused many organizations and institutions around the country to think of more humane ways to deal with the economic downturn.

When I asked for your help back in March, I was confident of the response. But I honestly did not understand the enthusiasm with which it would come. I knew that we viewed ourselves as a family here. But I did not fully understand the degree of affection and mutual commitment that underlays our hospital. We together lived through something very special, and I was especially honored to be your CEO during those weeks.

What now? I will talk about next year's budget, but first want to give an overview, at least as I see it. First, some "business school" type of background. I apologize if this is a bit dense and financially technical, but it will be helpful for you to understand the overall picture. I have also provided embedded links to my blog on some of the topics I mention, in case you want to delve into them further. Stick with me through this, please -- even if some of the terminology is new to you -- because I would really like you to understand the financial environment in which we carry out our important societal missions of patient care, research, and education.

As an academic medical center, we have been engaged in a successful business strategy that is composed of five elements: (1) create a broad referral network of trusting primary care doctors, specialists, and community hospitals; (2) emphasize those high level tertiary and quaternary specialties in which we excel, where we can gain market share, and which are highly reimbursed; (3) create a thriving environment for clinical care, research, and education that makes us attractive for the world’s leading clinicians and researchers; (4) negotiate favorable insurance reimbursement packages with insurance companies; and (5) pursue unrestricted philanthropy and gifts directed at clinical, research, and educational priorities.

We have had specific financial targets during this period. To renew and replace infrastructure in our buildings, to stay up to date with the latest clinical equipment, and to invest in our research enterprise, we should be prepared to make annual capital investments in the range of 130% of depreciation, or about $90 million per year. To generate this kind of cash, we need to earn a sustained operating margin of at least 4% supplemented by philanthropy directed specifically to capital purposes. In the years following the merger of the Deaconess and the BI, the hospital’s finances suffered, and capital investment did not meet this standard. Following the turn-around in 2002, we were able to earn a sufficient margin to start to make up for this shortfall, and by FY2008, we had substantially narrowed the gap on a cumulative basis.

There is nothing on the national or state political and economic scene to suggest that the coming years will offer good news for us and for other hospitals. Unless we act decisively, it is reasonable to expect a slow and steady deterioration in our capital position, our ability to compete, and ultimately our ability to carry out our mission in a manner that meets the standard of excellence we demand for ourselves. Putting aside the ups and downs of the economy, there are two major reimbursement factors that are likely to come into play. First, the rate of increase in reimbursements from both the government and private insurers will, at best, rise at the overall rate of consumer spending (not medical sector inflation). Academic medical centers like ours will especially see this. Second, there will be a tendency on the part of both types of insurers to move more to a capitated or bundled form of insurance that will require allocation of revenues and risk between the hospital and its affiliated doctors, but also between those two groups and other institutions in continuum of health care delivery (e.g., skilled nursing facilities and rehabilitation centers.) In others words, there will be something like an annual budget per person for health care, as opposed to the current fee-for-service type of pricing, where we get paid for each diagnosis and procedure and treatment we offer.

So, notwithstanding several years of success based on this business model, we need to recognize that the coming period will introduce new pressures on BIDMC. It is hard to envision exactly how we should respond to those changes. But we know, directionally, what we need to do:

1) We need to retain and enhance our focus of safety and quality and eliminating harm to patients. Beyond the obvious humanitarian reason for doing that, there is also a business imperative. We should anticipate that there will be greater public policy pursuit of quality and safety improvements, most likely characterized by failure to pay for certain procedures with adverse outcomes (e.g., “never” events and returns for follow-up surgery). There is also likely to be discounting of the capitated rates referred to above for failure to meet defined safety and quality metrics. These punitive steps add impetus to the existing business incentives for pursuing quality and safety improvement. Those incentives are expansion of market share from referring sources who value quality and safety and the dollar savings that accrue to the hospital by avoiding costs associated with patient harm.

2) We need to improve the way we organize work at the hospital to make it more efficient and less expensive. We have taken some baby steps in this direction with BIDMC SPIRIT. This program incorporates "Lean" type of thinking by encouraging people to call out problems in the work place, analyze those problems to their root cause, and invent solutions. If done right, this kind of continuous process improvement makes a safer and more pleasant workplace for our staff. When I started up SPIRIT, I told you that the design and approach of the program itself would change over time as we learned from it. Many of you joined in with enthusiasm and accomplished some great things, but then you felt that the effort had reach a plateau and sagged over time. Indeed it did because we recognized that we had not done sufficient training -- particularly of managers -- to give them the support they need to make it work. So stay tuned for more on that front.

3) We need to create stronger relationships with the insurers (especially Blue Cross, Harvard Pilgrim, and Tufts Health Plan) to ensure that our quality control and efficiency programs are recognized by them and rewarded in reimbursement methodologies.

4) We need to enhance and expand our clinical relationships with community hospitals and multi-specialty groups to provide a specific focus on quality and safety, to ensure that patients get the right type of care in the right place, but also to provide a dramatic improvement in the communication about patients' needs and the status of their care.

What does this mean this summer as we prepare our budget for FY2010? There are lots of moving parts. We will soon announce some new clinical affiliations in the community, and those will bring additional patients and revenue to BIDMC. But the reimbursement changes that are headed our way mean that we cannot just continue to spend money in the historical way to serve those patients. We need to organize our work differently to reduce overuse of testing and clinical procedures, some of which have been profitable in the past. We need, too, to be attentive to the levels of staff we need in various functional areas -- increasing some and diminishing others -- but doing so in a way that incorporates your suggestions for improving work flow and creating a safer environment. Because of financial pressures on the clinical side of the house, the margins that have traditionally supported research have shrunk, and so researchers too will have to meet more explicit financial targets. We will be gradually redesigning our education program so that efficiency, quality, and safety in clinical functions is more explicitly supported by our house staff, something that will also enhance the academic value of our training programs.

I recognize that these are just generalities at the moment, and you probably want to know, "What does this mean for me?" The nature of these global changes is that we all will see effects on our work lives, but they cannot be predicted exactly. Some people find that exciting, and some people find that scary. It will be a little of both. What I can promise you as we go through this is that we will do it together, with everybody sharing all the same information, with lots of opportunity for consultation and participation. The truly great organizations, like ours, are not afraid to face the future when we know we are doing it together.

Sunday, June 28, 2009

A few days ago, I wrote about the inconsistencies in the President's and Congressional descriptions of a public health insurance plan and suggested that it had other purposes than the ones they were describing. I now find a kindred spirit in Clive Crook at The Atlantic, who notes:

[I]t is surely disingenuous to say that a public plan can be just another competitor. How can just another competitor "keep them [the private insurers] honest"? If the public plan makes a difference it will be because of its market and political power, and because of its ability to attract subsidy--in short, because it is not just another competitor. If in turn it exerts those pressures, Obama's pledge that nothing will change for Americans who have private health insurance they like will be impossible to honor.

As I note above, if Congress wants to do this, it must be for the express purpose, first, of giving access to insurance to people at a lower cost, thereby reducing the amount of appropriations needed for subsidies of lower income people. And, second, over time, using those cost advantages to cause more and more people to migrate to the public plan. Perhaps those are the right answers for the country, perhaps not. But let's debate those directly, instead of using fuzzy arguments.

Friday, June 26, 2009

This picture was just too cute not to post it, to carry you through the weekend. Here is the explanation from the mother about her son's first "official run."

We live in Fair Oaks, in which our "Old Village" area features a little park that's populated by a band of chickens. There are many varieties, and some of the roosters have spectacular, colorful plumage. We go to the park and feed them, and they wander around the Village, even at the fine outdoor restaurant. It's our trademark; although some would prefer that our oaks, bluff, and beautiful reach of the American River would take precedence. In the festival's running events, the children are escorted by two adult runners wearing outrageous chicken costumes.

Thursday, June 25, 2009

Robert D. "Don" Lowry, former CEO of the New England Deaconess Hospital, passed away peacefully at his home in Chelsea late Monday, June 22, at the age of 95. Don Lowry made innumerable contributions to this hospital, but I will miss him most for his quiet and calm demeanor, and his kind generosity of spirit. What follows are excerpts of our notice to staff this week.

Don was employed at the Deaconess for 30 years. He became its Chief Executive Officer in 1954, a position he held until his retirement in 1976. He remained on the Board of Directors for several years thereafter, and when the hospital later merged to become Beth Israel Deaconess Medical Center, he was named a Trustee for Life.

The Lowry Medical Office Building at 110 Francis St., was named to honor Don’s many accomplishments during his tenure at the hospital. He was beloved by his employees for his humility, his friendliness and his willingness to pitch in and do whatever he asked of others. An enthusiastic supporter of nursing education, he was admired and highly respected by the nursing staff, the physicians, and the trustees, many of whom became close friends. Under his popular leadership, the Deaconess grew from 298 beds to a 482-bed specialty referral hospital known throughout the world for the treatment of diabetes, heart disease, and cancer.

"Don had the reputation of being a great builder – but being a builder of buildings was not what made him a great leader,” notes his friend and former colleague Joanne Casella, Chief Administrative Officer, Department of Medicine. “It was that he was a builder of trust."

Don had extraordinary warmth and empathy for people of all ages and positions, and he made everyone comfortable in his presence. Many friends and employees were drawn to share their problems with him because, even if he were unable to find a solution, he would leave them feeling comforted, respected, and less lonely and discordant. He loved the people he worked with. As one trustee said at his retirement dinner, "Don's talent has been to bring people around to his way of thinking. He never argued. But soon I'd find myself doing what he wanted me to do...and happy to do it...and thinking it was all my own idea."

Don was born and raised on a farm in Doniphan, NE, a town of about 300. His father later became a grocery store owner and Postmaster. His mother had been a school teacher. After graduating from Doniphan High School, Don worked for several months in a commercial photography studio in Hastings, Nebraska, before moving to California in 1931 where he attended Sacramento College.

In March of 1941 he was drafted into the U.S Army and, when World War II was declared in December of that year, his nine-month stint was extended to five years. In the Army, he helped to set up an X-ray department and trained X-ray technicians at the Station Hospital in San Luis Obispo, Calif. He was commissioned in the Medical Administrative Corps in 1942 and, as a Captain, served as adjutant to the 102nd Station Hospital in Australia as well as in New Guinea, the Netherlands East Indies, and the Philippines, eventually leading to his life's work in hospital administration.

Photography remained Don’s avocation for many years. And, his other great joy in his "off" time from the Deaconess was his 34-foot cabin cruiser, "The Sequester," on which he spent many happy hours entertaining family and friends during the summer months, often serving them a unique sandwich he called the "Sequester Special."

While leading the Deaconess Hospital, Don served terms as President of the Massachusetts Hospital Association and President of the New England Hospital Superintendent's Club. He was an active member of the New England Hospital Assembly, the National League for Nursing, and numerous other hospital-related groups, and remained a Life Diplomate of the American College of Healthcare Executives. Upon his retirement from the Deaconess, he was honored by a vote of the physicians to be named an Honorary Member of the Medical Staff.

Don also was a board member of the Morgan Memorial and in the 1950s a founding member and senior warden of St. John's Episcopal Church in Westwood, and head of its Building Committee. For several years in the late-1970s and early-1980s, he served on the governing board of the Old North Church in Boston where he was a lifelong member of the congregation.

He leaves his wife of 30 years, Eleanor (Clapp) Lowry (a longtime Volunteer Surgical Liaison), family and many friends.

With medical education focused so heavily on the cause of disease, diagnoses, and therapies, an area that is usually neglected relates to the science of care delivery and process improvement. We're trying to make some inroads here. I told you about one below, and here's another.

Three of our interns (Maryanne Kazanis, Nina Nandy, and Paul Bailey) are participating in a pilot educational experience in quality improvement. As noted by Dr. Julius Yang, who is coordinating the effort, "This is not yet standardized for all new interns, as we are trying to learn from these three whether this is worth expanding to a larger group in the future. The pilot experience is an outgrowth from our participation in the ACGME Educational Innnovation Project, where we are attempting to incorporate continuous health systems improvement skills in the standard training for all our residents."

Julius reports about the first two days: After a whirlwind morning introduction to the field of health care quality and “lean practice” (facilitated by a video that features making toast in a less wasteful way), this group spent an afternoon with clipboards and stopwatches (on day 1 of internship) to observe our current discharge process – using their “uncommitted eyes” to watch the process from the perspective of both nursing and physician workflow. They then spent the next day generating a “future state” concept of what attributes would comprise the ideal discharge process, complete with very near-usable “checklists” (one for the patient, one for the physicians) to help standardize the process.

To give you a sense of the perspicacity of our new doctors, here are just a few excerpts from their observations (some of which paralleled our senior management visit to gemba). Not bad for two days on the job!

GOALS:To highlight the less efficient aspects of the patient discharge process from a nursing perspective.To provide a standardized patient discharge protocol for the nursing staff.To explain why the recommendations implemented in a more standardized discharge protocol would lead to a more efficient discharge process overall.

ASPECTS REQUIRING IMPROVEMENT:Waiting:Discharge orders are often entered by the MD at a time that is later than ideal for the nursing staff. This especially contributes to a less efficient overall process when nurses have multiple discharges to complete at once, and when the patients to be discharged are particularly complicated and require more time/teaching by the nursing staff.

Another issue that arises with later discharge order entry is that patients are left to wait 8 hours or more from the time they are told about discharge in the morning to when they are actually free to leave the hospital. This leads to increased questions by the patients to the nursing staff, pages to the MD, potentially displeased patients, and fewer beds available for new patients awaiting admission from the ED.

Forms:The completion of online forms at this time is redundant with nurses cutting and pasting much of the same information into the patient’s copy of the discharge summary that the MD completed for the permanent medical record. In addition, some online forms include default information that is not relevant to all patients and require frequent deletion by the nursing staff.

Medication reconciliation:At the time of admission, ED physicians are not consistently completing the handwritten carbon-copy version of the medication reconciliation form and filing it in the patient’s chart. As a result, nurses are required to transcribe by hand this information onto the carbon-copy form which can be quite time consuming.

Obtaining and recording vital signs, removing IVs, and completing medication reconciliation:At the current time, nurses are often making multiple trips back and forth to the patient’s room to do these items at separately. This leads to inefficient use of time walking back and forth, and may potentially lead to errors in excluding an important part of the discharge protocol.

Wednesday, June 24, 2009

A short excerpt from a more extensive letter to Governor Deval Patrick from the President of the Massachusetts Hospital Association. The idea that coverage under the Massachusetts universal coverage law would be taken away from legal immigrants is deeply disturbing.

Dear Governor Patrick:

The Massachusetts Hospital Association (MHA), and its member hospitals and health systems urge your veto of section 121 of HB4129, the legislature’s FY10 state budget proposal. This section represents a significant step backward in the Commonwealth’s health care reform initiative by eliminating Commonwealth Care Coverage for 28,000 special status legal immigrants currently enrolled in the program.

...We believe health coverage should extend to all legal immigrants, not just those that meet an arbitrary time period of residency. ...[B]eyond the deviation from our goal of near universal coverage, this action also moves us in the opposite direction to better control healthcare costs. These 28,000 people would have less access to prescription drugs and preventative care, including that provided by independent primary care physician practices and mental health providers. The primary access point to medical care for these patients will again become the hospital emergency department, one of the more expensive settings in our system. And while the legislature’s proposal assumes a $130 million state financial savings, the Commonwealth’s true savings will be much less. That is because hospitals and health centers will continue to provide the care they currently do and will pick up the added care associated with loss of coverage from other medical providers and services.

- These Commonwealth Care enrollees are legal, working, tax-paying residents of our Commonwealth, deserving access to services like the rest of our neighbors.- This is a counter-productive cut, consigning people to the unmanaged, episodic Health Safety Net for services.- The cut will place additional burden on our beleaguered community hospitals and health centers.- Eliminating coverage will reduce access to care and reverse the incredible gains we have made through health reform.

I believe that this is a test of the state's resolve to deliver what was promised in Chapter 58. And, while the President and Congress place great faith in our experiment, the resolution of this issue will also send a broader signal to those involved in the national debate.

Fit testing is required at BIDMC and other hospitals to help insure that health care workers who could be exposed to airborne infection have the correct mask to use and thereby minimize the risk of exposure. The testing involves a series of exercises while being exposed to a "bitter" or "sweet" tasting spray of solution. If the mask is fitted correctly you should not taste the solution that is sprayed into the yellow hood.

Each department has a designated person who does the testing. Nurse Judi Hirshfield-Bartek, shown here, makes this important task more fun by adding a few exercises like jumping jacks and silly things that make people laugh. Also, since some people find the test a bit claustrophobic, the games distract them and help them get through more easily.

Here is a picture of our entering class of residents at their orientation session. What, you don't see anybody? Well, it is because these are the rows at the front of the auditorium. There seems to be some kind of Darwinian imperative -- perhaps based on their experience in undergraduate medical education -- for trainees to sit in the back rows. If you go back a few rows, you can find people, like these three new Emergency Department residents, seen with Dr. Sean Kelly, head of our graduate medical education program.

Monday, June 22, 2009

One of the lessons of Lean is that if you standardize work, you not only reduce variation, but you improve the quality of the product or service. This is known to be true in the delivery of medical care, but it is often not practiced in hospitals. Instead, hospitals remain cottage industries, with each craftsperson (doctor) plying his or her craft (clinical care) on the basis of experience, intellect, and creativity rather than on the basis of scientific evidence. This leads, nationwide, to extension variation in practice patterns (and cost). More locally, it leads to greater potential for harm. What we need, instead, is a greater reliance on standardized practices in those portions of medical care than can and should be standardized -- still leaving to doctors their ability, creativity, and craftsmanship for those circumstances that truly demand those attributes.

This pig game demonstrates the value of standard work flows. It's fun and illustrative of the concept. Find some friends on whom you can experiment. We'll start with this posting in round one, and then rounds two and three follow below. First, prepare standard size pieces of paper with the grid shown above -- one per participant. (If you click on the picture of the grid, you will get an enlarged version you can print out on paper.)

Now, read the following instructions to your friends: You'll probably have to repeat the instructions.

1) Draw the side profile of a pig, centered on the page.2) Make sure the pig's head is facing left.3) The pig should be drawn large enough so that a piece of it is in every box EXCEPT the top right.4) You have 2 minutes to draw your pig.

Now, have everyone show their pig drawing to everyone else. OK, go to round two, below.

Welcome from round 1 of the pig game. Now we turn to round 2. This time, hand out the instructions above, along with another copy of the grid, and ask people to draw another pig. Again, have everyone compare their results. Now go to the next step, below.

Turning from round 2, we go finally to round three of the pig game. Hand out this set of instructions, along with another grid. Now, compare the results of the participants.

I'm guessing you will see higher quality pictures and more uniformity. All right, I know this is not a clinical procedure, with all of its potential complications, but the lesson is nonetheless powerful. After our residents took their Lean training course, several of them said this was the most powerful lesson they learned. They now apply it in clinical settings, looking for "pigs" to standardize their work where appropriate.

Remember, we are not trying here to standardize those parts of patient care that should not be standardized; but we are trying to do so for those elements of care than can be and, most importantly, should be to reduce and eliminate harm. In our hospital, we have done so in the following arenas among others. This has saved lives and reduced other harm, plus making life better for staff and patients:

Sunday, June 21, 2009

The Commonwealth of MA Health Care Quality and Cost Council will be holding its Annual Meeting on June 25 from 8:30 am to noon.

For the last year the QCC has worked to:• Establish statewide goals for improving quality, containing costs, and reducing racial and ethnic disparities ; and demonstrate progress toward achieving those goals. Areas of focus have included chronic and end of life care, patient safety, and building a road map for cost containment. Info on each can be found at the QCC website.• Disseminate, through a consumer-friendly website and other media, comparative health care cost, quality, and related information for consumers, health care providers, health plans, employers, policy-makers, and the general public. Updates to and enhanced community education about the website occurred.

The keynote speaker will be Cathy Schoen, Senior Vice President at the Commonwealth Fund, and lead researcher on the Commission on a High Performance Health System’s State Scorecard. Ms. Schoen will be speaking about health care system redesign and aligning outcomes with payment reform while sharing new data from the Commissions’ 2009 State Scorecard. A panel of local reactors will feature Senator Richard Moore, Dr. Charlotte Yeh of AARP, Dr. Randy Wetheimer of Cambridge Health Alliance, and Eileen McAnemy of Associated Industries of Massachusetts. The Council will set its agenda and priorities for FY10 in small work groups with audience members.

The meeting will be held at the Hoagland-Pincus Conference Center at UMASS Medical School. A light breakfast will be available for $5 a person. Please register here.

Lisa Neal Gualtieri, Ph.D., Adjunct Clinical Professor, Tufts University School of Medicine asks me to post the following announcement:

Enroll in the Tufts Summer Institute on Web Strategies for Health Communication, to learn how you can help health care organizations develop and implement Web strategies to drive the success of their online presence. Health care organizations are faced with an ever evolving choice of Web technologies that make it challenging to create a coherent and justifiable Web strategy. At the Tufts Summer Institute, you will learn how to select, use, manage, and evaluate the effectiveness of Web technologies for health communication.

Learn from Tufts faculty and distinguished guest speakers how to: • Use the Web to communicate with and connect to patients. • Develop a coherent and justifiable Web strategy for health communication. • Select and manage Web 2.0 technologies to create a Web presence that provides a rich user experience. • Accelerate your online presence through the use of social media sites and tools such as Facebook, twitter, ning, and Wordpress. • Employ research-based methodologies such as persona development and formative evaluation to increase the effectiveness and reduce the risk of Web development projects. • Learn the best practices employed by leading health Web sites including WebMD.com, MayoClinic.com, CDC.gov, TuDiabetes.com, WeightWatchers.com, Livestrong.org, CureTogether.com, Roadback.org, and ABC News Health.

Web Strategies for Health Communication runs July 19-24, 2009. The course meets at the Tufts University School of Medicine campus in Boston from Sunday, July 19, from 5-8 p.m. and on Monday-Friday, July 20-24, from 9 a.m. – 5 p.m. It is offered through the Health Communication Program at Tufts University School of Medicine.

The current Washington debate about creating a public health plan has a lot of fuzzy arguments. I think everybody can agree that a government insurance company would have lots of cost advantages over private insurers -- lower or no reserve requirements; avoiding regulatory requirements of the states; and, with regard to the for-profit companies, not paying taxes and trying to meet the expectations of equity shareholders.

So, if Congress wants to do this, it must be for the express purpose, first, of giving access to insurance to people at a lower cost, thereby reducing the amount of appropriations needed for subsidies of lower income people. And, second, over time, using those cost advantages to cause more and more people to migrate to the public plan.

If the purpose were just to provide access to people, the existing insurers could be ordered to provide it in much the way the Netherlands has, and also the way Massachusetts has. Then, the full amount of public subsidies for low income people would require appropriations and would be evident to all.

So, I think the proponents of a public health plan really want two things. They want to hide the cost of universal health care access. And, ultimately, they want a greater and greater percentage of the population to be on the public plan.

Thus, the arguments you see about a public plan being set up to encourage more competition among health insurers just don't hold water. So, let's be more direct about the real purposes and vote those up or down.

Friday, June 19, 2009

We know from recent headlines about scoundrels from the American financial scene to the halls of European parliaments - and we can certainly do without either. But the problem extends into every area of human enterprise. When a construction company cheats on the quality of materials for a school or a bridge, when a teacher skimps on class work in order to sell his time privately, when a doctor recommends a drug because of incentives from a pharmaceutical company, when a bank loan is skewed by kickbacks, or a student paper is plagiarized from the internet - when the norms of fairness and decency are violated in any way, then the foundations of society are undermined. And the damage is felt most immediately in the most vulnerable societies, where fraud is often neither reported nor corrected, but simply accepted as an inevitable condition of life.

Pluralism means not only accepting, but embracing human difference. It sees the world’s variety as a blessing rather than a burden, regarding encounters with the “Other” as opportunities rather than as threats. Pluralism does not mean homogenization - denying what is different to seek superficial accommodation. To the contrary, pluralism respects the role of individual identity in building a richer world. Pluralism means reconciling what is unique in our individual traditions with a profound sense of what connects us to all of humankind. . . . A pluralistic attitude is not something with which people are born. An instinctive fear of what is different is perhaps a more common human trait. But such fear is a condition which can be transcended.

We have . . . learned that simplistic systems don’t work; whether built around the arrogance of colonialism, the rigidities of communism, the romantic dreams of nationalism, or the naive promises of untrammelled capitalism.

I don't claim to know much about medicine, still being relatively new to the field, but I do understand public policy and politics pretty well. A short while ago, I wrote here, with regard to Washington's consideration of health reform:

Meanwhile, hospitals, do you see the hand-writing on the wall? Academic medical centers have the most to lose here: There is no natural constituency in Congress to provide high levels of support for graduate medical education to these high-cost hospitals. While there is a community hospital in every Congressional district, academic medical centers are much fewer in number and concentrated in just a few districts. Count the votes.

Today's New York Timesgraphic confirms this, listing ideas under consideration by the Senate Finance Committee:

• Establish an “automated mechanism” to rein in Medicare costs like the one used to close military bases.

• Reduce geographic variations in Medicare spending by cutting or capping payments in “areas where per-beneficiary spending is above a certain threshold, compared with the national average.”

• Cut special Medicare payments to teaching hospitals.

The first item would likely exclude those innovative, but often high-cost, diagnoses and therapies that get their start in academic medical centers.

The second item would reduce reimbursement rates where AMCs are often located, in urban areas that require higher wages and salaries for hospital workers.

And here's the code for the third item. Those "special" payments are what fund graduate medical education -- the residency programs that train the next generation of doctors.

Please read this story in the Boston Globe by Liz Kowalczyk about a grant our folks just received from the Robert Wood Johnson Foundation to test out the proposition that patients should have access to all of their doctors' notes about them.

This day will never comeagain. The flaming yellowforsythia in Cambridge Common,although it may returnyear after year, will not bloom the same —

ever again.

The light, the day, the number of blossoms,the color, the shape, the people passing by,and the way the clouds move across the sky:

All will be different.

And so, with the fiery red tulips,bursting forth in neighbors’ yards,or the magnolia trees in the Back Bay,or the many apple, plum, and cherryblossoms that light up this New England day.

What I see today, willNever again be the same,

neveragain the same.

And as it is for the bursting flowers andblossoming trees, so is it also

for you, and for me:

Today’s thoughts, pains, loves,and Dreams – the way we feel and touch today,although all may seem, to return againtomorrow, and the next day, will never again –NEVER return again as on this day:

Never again like today.

Today, the subway glides across the Charles River;Monday morning commuters look up briefly fromtheir Heralds and Globes and seesky and water a slate gray.

A lone sea gull veers into view.

Along the Boston Esplanade, black(still winter) tree limbs vie with cherryblossoms and tiny green leaves. And inthe distance: the Prudential Tower is adark shadow in the Hancock’s blue glass.

Although it is already late April,snow is predicted later today.

Moving forward beyond the Charles T-Stop,an island of red, yellow, orange and pink tulipsgreet us far below at the entrance of Charles Street.

The tulips yell to us: “STOP! LOOK!”Before it is too late.

But, it is already too late . . . .

as we once again enter the subway tunnel,high above the tulips, moving towards Park Street Station,neither pausing or stopping, or putting on the brakes.

Most of the passengers go back to their books and newspapers.Others start to prepare for the morning onslaught at the nexttrain stop, positioning themselves in their seats, putting on their packs.

This April, I feel like I am missing the Spring –all of its poetry swallowed up by thedeadening prose of incessant busy work,morning and evening commutes, andadministrative demands.

Time feels squandered – asecond, a minute, an hourat a time – days and weeks passing,then months, and finally years,in a gray foggy blur of too long ofwork weeks, piling up like loads ofstacked lumber ready for sale.

Always on someone else’s time. . . .

Time feeling scrunched up now; lifepassing like a subway ride, moving forwardday after day to work, watching the seasonscome and go behind steel, concrete, and glass,but not feeling a part of the Spring;Instead, only counting grains of sandfalling through an hour glass:

today, and day after day.

At Kenmore Station, I get off.Having to change trains again,I wait patiently in the dimly litwaiting area for my next ride:

When he worked here, the current CEO of the Caritas Christi system would often look wistfully to the south and ask us to consider taking over the troubled Landmark Medical Center in Woonsocket. We put the kibosh on that idea faster that you can say, "State of Rhode Island and Providence Plantations."

Now, according to this Boston Globestory by Rob Weisman, he is pursuing the same plan. I think it's time for the SEIU to investigate this. After all, they are keen on increasing state aid to a financially troubled Massachusetts hospital in the Caritas system. They can't also be in favor of transferring those state funds and charitable assets to support a financially troubled system in another state.

What's the real play here? Perhaps it is the hope that cardiac surgery cases from Landmark would be referred to St. Elizabeth's Hospital, a Caritas subsidiary. How that would help Rhode Islanders is an interesting question. Would the Boston-based doctors and hospital be paid Massachusetts-level insurance rates, which are higher than Rhode Island's? How would Blue Cross of Rhode Island feel about that? Perhaps the doctors and hospital would be paid the lower-than-Boston-market Rhode Island rates? Would Rhode Island's Lifespan system stand by idly and watch this business leave their hospitals?

This is all too hard to understand. It seems to me that if you strap two leaky lifeboats together, they sink faster. Perhaps people could be more transparent about their intentions and hopes.

Classes may be over for the year at colleges and medical schools across the country, but one school stays open day and night, the Institute for Healthcare Improvement's Open School. Back in December, I wrote about the open thread covering the wrong-side surgery that occurred at BIDMC last July. It still goes on, with comments filed several times a week.

When we publicized this "never event" through our hospital, our main purpose was to inform our staff so they could learn from it, and so that our remediation planning would have hospital-wide participation and support. That goal was achieved, demonstrating the power of transparency in this kind of setting.

But our purpose also was to splay this case out for the world to see, to provide lessons for other hospitals. Doing so is consistent with our role as an academic medical center and our societal objective of reducing harm to patients, wherever they are treated. IHI's Open School has played an important part in that process, and I am grateful to them for making the service available -- at no charge -- to the entire world. Read the comments and participate: There is good stuff happening on-line. School is always in session.

Wednesday, June 17, 2009

Speaking of residents, our Board of Directors today presented this month's Caller-Outer of the Month Award to Adam Fein, MD, a second year medical resident. Regular readers will recall that this award is presented by the Board to reinforce the underlying concept of BIDMC SPIRIT -- that each person should be encouraged to call out problems in the workplace and be recognized and appreciated for his or her contribution to safety, quality, efficiency, and a better work environment.

One of the annoying things about leaving a hospital is that the discharge process often takes a long time, leading to frustration for both patients and families. Adam diagnosed a source of those delays: The residents who were arranging follow-up appointments with hospital-based specialists were calling each specialist's office one at a time. This discharge step was often the lowest priority for residents: After all, patients who were still sick and needed care would instead get their attention. Meanwhile, the healthier patients waiting to be discharged would, in fact, be waiting for the resident to make those follow-up appointments.

As it turns out, we have a service for referring physicians in the community who need to make appointments with our specialists. They send in their request to a centralized referral command center ("RefComm"), where a nurse acts as the liaison in setting up appointments and communicating with all parties. As a result of Adam's call-out, the RefComm service center was also made available to the residents. Instead of making all the follow-up arrangements themselves, they simply send an electronic request to the folks at RefComm, who take care of things. This frees up the residents to carry out their doctoring duties and accelerates the discharge planning process.

Adam received a congratulatory letter, plus second row dugout tickets to a Red Sox game of his choice.

Our senior executive Lean training program always has a visit to gemba as part of the day's session. This time, we went to one of the clinical floors to watch the process of work rounds. The purpose was mainly for us to practice using Lean tools to gather baseline data and identify variation in the work process.

Here's a picture of intern Elena Resnick reporting to resident Lauren Fishbein. Our doctors in training do an excellent job, but we noticed many opportunities for better integration of their activities with those of other departments in the hospital (e.g., radiology, pathology, and case management). However, that would require a massive shift in the mode and purpose of work rounds, attributes which have been in place for decades as part of the design of the medical education process.

We'll come back to this problem some day in the future. For now it was an illustration of the degree of complexity of an academic medical center, where the delivery of clinical care is intimately -- and often inefficiently -- connected to the delivery of undergraduate educational services to medical students and graduate medical education to residents.

Tuesday, June 16, 2009

There is the substance of health care reform, and there is the politics of it. David Brooks ably addresses the latter in today's column in the New York Times. Even with a single party in power in Washington, it has become clear to all that the President cannot deliver on his promised "access-choice-lower cost" trio. So now the aim will be to claim political victory with a bit less expanded coverage, cuts in Medicare payments to providers and minor tax increases, while also using accountable care organizations to reduce choice. At the bill signing, Mr. Obama will assure us that we have obtained the full three-part package, even if the total is less than the sum of its parts. It will be years before the full implications are understood.

Along those lines, for those concerned about the long run, beware the modified public plan option that uses the benefits of government ownership and the federal supremacy clause to underprice private insurers, in part by avoiding the costs and regulations of state jurisdiction. This taxpayer-supported plan will, in time, become dominant. It will start by drawing off two categories of people: Low-risk, young healthy people who will be required to have insurance but who will want a lower-cost plan; and higher cost, less healthy people who will be happy to join the new public company at rates lower than they can obtain from private firms. The actuarial facts of life of the latter group will force the government to give greater and greater subsidies and preferential treatment to the new GM, which will in turn make it ever more attractive to a growing base of the population. Instead of this plan, as I have mentioned, why not use the approach of the Netherlands to ensure access?

In the current debate on health care reform in Washington, the chance of a single payer system emerging seems to be very small. I think that's fine. Three years ago, I made this point, citing a portion of the book Redefining Health Care, by Michael Porter and Elizabeth Teisberg.

Now, Clayton Christensen and his co-authors reinforce this view in The Innovator's Prescription. They note (on pages 400-401) that "almost every government with nationalized health care has been forced to ration access to advanced care in one way or another. . . . As a result, most countries with national health systems have had to develop alternative market-based channels for coverage as well -- so people can choose for themselves whether to pay for certain services, rather than leaving that choice to bureaucrats."

They further note, "Because of governments' tight control on caregivers' salaries, in many nations the best physicians establish themselves in private practice, where they can earn higher incomes by serving the wealthy. This is another paradox of national health system: while the intent is to assure universal access, often it is the elite who see the elite, while the rest see the rest.... We ... urge America's political leaders not to view further government control as a vehicle for solving our problems."

I have made similar comments based on my trips abroad, in Iceland, the UK, and elsewhere. When we look at the complexities and flaws of the US system, it is easy to think the grass is greener elsewhere, but it really is not in many respects. But, where we can certainly learn from those countries is the importance of putting greater emphasis on primary care. Interestingly, Medicare could do that tomorrow by changing reimbursement rates for primary care evaluation, diagnosis, and disease management types of services. But, as Brian Klepper noted some time ago, this is viewed as a zero-sum game by the specialists, and so those proposals do not make progress. (Thanks to Charlie Baker for linking to Brian's post over a year ago.)

Monday, June 15, 2009

A little more on Clayton Christensen's view of the health care world, as set forth in The Innovator's Prescription. I have noted below his conclusion that general hospitals do not have a sustainable business model. He is persuasive on this point. What's the solution? Here are the key elements, from page 198 of the book.

[E]ntities that could integrate a new value network are large providers that create and knit together underneath their corporate umbrellas all of the necessary elements of the new value network. There are several important characteristics of such integrated health systems.

First, they operate their own insurance and payments systems. Patients or purchasers in the system pay a fixed fee, typically yearly, that covers the cost of all care they might need. Second, the physicians are essentially employees of the system, not independent businesspeople. Third, the caregiving institutions in the system are apt to use focused business models…. They can operate a limited number of general hospitals, while rationally siphoning work out to coherent solution shops and value-adding process clinics, outpatient clinics, and even retail clinics. And they have created and operate an information system that glues these different providers together to properly coordinate care. Finally, these firms are large employers themselves.

As some of you know, I used to run the regional water and sewer system in Eastern Massachusetts. Among the things I liked best: I was providing an essential public service, I had a monopoly, I could set my own prices, and people had to pay.

There are a few parts of the country in which a similar system exists for health care. For most of the country, this is not the case. If we want to create such entities, who will decide how many there should be and who will control them?

Sunday, June 14, 2009

I've been thinking a lot about Clayton Christensen's comment that the traditional general hospital is not a viable business model, and especially so for general hospitals that are also academic medical centers. I'll have more on the business implications of that conclusion in a future posting, but I want to take a moment to explore one ramification. It occurred to me during a panel discussion with Harvard Pilgrim's Charlie Baker and health care consultant Jeff Krasner (seen here) at the Convergence Forum a few days ago.

People often comment on the fact that a lot of discoveries made in academic medical centers result in new diagnoses, therapies, and devices that add to the cost of health care. And that is true. Our society does not generally conduct a cost-effectiveness analysis on new developments in the field, focusing mainly on medical efficacy and, indeed, business viability. But it is also true that academic medical centers are the place where the creativity of physician-scientists goes to work every day to develop ideas that can really make a difference.

Our Chief of Radiology, Jonny Kruskal, recently told me about a recent example. One of our young radiologists, Ivan Pedrosa, had a hunch about how to deal with the tricky diagnostic problem of pregnant women with pains in the lower right abdomen, which might or might not be appendicitis. Ultrasound does not give a reliable answer, and CT scans are problematic because of radiation. Ivan believed that use of MRI might produce more reliable answers than the former and with less chance of harmful side effects than the latter. Following some experimentation, he and his colleagues were able to prove the hypothesis and publish their results. The study has now been widely circulated (for example, here), and this approach is now expanding as the new standard of care.

Please accept my non-doctor apologies if I don't have the story and the science exactly right, but I think the point is clear. There is a societal advantage to have academic medical centers like BIDMC, as places where many medical advances occur -- often unreimbursed by insurers and the government. That contributes to the lack of viability of our business model, along with the many other factors mentioned by Clayton, but it makes more urgent the question that derives from Clayton's analysis. How do such centers survive and thrive in the environment of disruption he has so ably described?

Saturday, June 13, 2009

It turns out that I have a very creative girls soccer team. I previously displayed Shira's email signature. Now, here's Madeleine's.

By the way, they are great players, too, winning their league's section with a decisive team record. The cake from today's end-of-season party is shown above. (Team name = Newton Girls Soccer Thunder.)

Friday, June 12, 2009

I'm sitting at home choosing to "watch" the Red Sox-Phillies game on the radio rather than on television. Why? Because radio announcer Joe Castiglione produces a feel for the game that is more evocative of being in the park than watching it on television. His play-by-play fertilizes your imagination in a manner that, for me, brings me back to my childhood. Here's a picture of Joe in the broadcast booth at Fenway Park last Sunday when I had a chance to visit him during our induction of the newest class of Red Sox Scholars.

Thursday, June 11, 2009

We were honored today to have a visit from Clayton Christensen, from Harvard Business School, addressing a group of our staff and a number of CEOs from many of the major health-science related firms in the Boston area. Clayton is famous for having developed the theory of disruptive innovation and has applied aspects of that construct to the health care field.

Clayton noted that disruption in business models has been the dominant historical mechanism for making things more affordable and accessible, and for generating corporate and economic growth. He pointed out that, compared to other industries, like computers and automobiles, the decentralization that follows centralization is only beginning in health care. The problem, he noted, is that the traditional general hospital is not a viable business model. He persuasively asserts that hospitals are expensive conflations of three types of business models: Solution shops that in other fields would be paid on a fee-for-service basis; (2) value-added process businesses that would be paid for on a fee-for-outcome basis; and (3) facilitated networks that would be paid for on a fee-for-member or fee-for use basis. He points out, too, that the agglomeration of many of these business lines and a desire to serve all kinds of patients results in a very high overhead burden rate -- roughly $9 for every $1 spend on direct patient care. He suggests that, within a general hospital, even the concept of focused factories has a tendency to be overloaded with overhead.

Where this all leads for general hospitals, and for academic medical centers, is not yet clear. Not all health care can be offered in "minute clinics," but a substantial amount could be offered in more specialized, decentralized centers than currently exist in an area like Eastern Massachusetts. This has not happened much yet other than with affiliates of the big teaching hospitals because people in Boston value the brand names associated with the academic medical centers; but the power of the purse is strong and over time will erode that brand loyalty. Unless, of course, the major player in Eastern Massachusetts is given free reign by the government to become the dominant Accountable Care Organization.

Rob Weisman at the Boston Globereports that workers at Caritas Carney Hospital have chosen to have SEIU represent them in collective bargaining. That the union was successful in this organizing campaign is unremarkable given the gag order neutrality agreement signed by the management of the Caritas system several months ago.

What is remarkable, though, is this: "Carney employees hope to improve their working conditions and pay and bring the union's clout to bear in pressing for more public resources for the community hospital, which has struggled financially." Carney already receives millions of dollars per year in public support. What an ironic turn of events that its success now relies on increasing that support while the state faces extreme financial problems.

Over the last several years, SEIU has spent hundreds of thousands of dollars trying to convince the public that BIDMC is inefficient and unsafe -- implying that the management is not competent and that our governing bodies are ineffectual -- and that only its press releases have led to improvements. So while the union has money to squander on a corporate campaign at a hospital in which it has no jurisdiction, it will seek more public funds for a hospital which it will be running.

Perhaps the community should hold SEIU to a different standard of accountability: Demonstrate that it can make Carney more efficient and reduce the amount of taxpayer support needed to keep it viable. Also, start to post clinical outcomes to demonstrate progress in improving quality and safety.

Wednesday, June 10, 2009

I have raised some questions below about the concept of "accountable care organizations," an idea that has gained prominence in both federal and state discussions. The idea, in short, is to combine a capitated form of reimbursement with a restricted network of providers across the spectrum of care. In its most expansive form, each of us citizens would have an annual health care budget, and your ACO would manage your care -- from primary care to secondary and tertiary care, and perhaps further to skilled nursing facilities or rehab, and maybe even through hospice if that was how far things went for you. Short of that, there might be "bundled" amounts of payment to cover acute care episodes of certain types or chronic disease extended care.

Let me now pose a different question. What would be the public policy incentive created by the government to cause institutions to band together to create an ACO? Presumably, health care institutions and physicians would want to know that it would be financially advantageous to combine under a single care management structure. So, first, someone would have to create insurance products that are attractive to consumers and employers. What would make it attractive to tell people that their choices of service providers will be limited to those contained in a given ACO? Well, at a minimum, they would have to be offered a lower price for their insurance coverage.

But, let's now turn back to the medical providers who were thinking of banding together to create an ACO. To garner customers who would pay less, you would have to be confident that your new group could deliver services at a lower cost than you previously would have expected individually and as a group. You would also have to be willing to take some portion of the actuarial risk previously born by the insurance companies or the government. You could do the latter by purchasing re-insurance or by building up your balance sheet to provide a financial buffer against miscalculations.

So, not only would you have to be confident of delivering services at a lower cost, but you also have to do so net of your new cost of absorbing greater risk.

When it comes to business planning, I am pretty simplistic. If the government wants to encourage ACOs, it seems to me that this construct will require the government to be co-investors in them. Either the government will need to create a mechanism to absorb risk, or it will have to offer direct subsidies to make it financially attractive for the the ACOs to agree to lower payment rates for the same services previously offered.

What am I missing? Well, you could argue that those who are contemplating the construction of an ACO could be confident of reducing their overall cost of health care delivery. They would also be confident that the consumer and employer market will rise to greet their new product offering. The two thoughts combined would make this an attractive business model. These market leaders would be willing to take that pricing risk for the sake of getting a foothold in the new world order of health care delivery.

It is hard for me to imagine this as a widespread phenomenon -- independent hospitals and physician groups and skilled nursing facilities and rehab centers having the wherewithal to do the business planning, the relationship building, the decisions about risk allocation, the construction of interoperable medical records, and the like that would be necessary to even evaluate the proposition -- especially in the face of a void in insurance products that would have been tested in the marketplace for their attractiveness to consumers and employers.

So, the question for President Obama and for Governor Patrick is, "What are you planning to offer to make this an attractive proposition for the medical professions and the institutions that provide care?"

When Rhonda Mann, a member of our staff, decided to have surgery with Dr. Paul Glazer to alleviate her scoliosis problem, she drew on her experience as a television producer to document the course of her treatment. Watch the video here for her compelling story. Channel 5 in Boston also covered the story here and here.

Rhonda reports, "I'm feeling terrific!" We are happy that all went well and that Rhonda chose to share her experience to benefit others who might face similar procedures.

Tuesday, June 09, 2009

Thanks to Dawna White and her colleagues from HFMA (Healthcare Financial Management Association) for the invitation to speak in an audio webcast today about our recent experience with staff participation in managing budget difficulties and avoiding hundreds of layoffs. We had 682 attendees from all over the country (see map for some of the participants). Instead of the usual Power Point presentation, I led the listeners through contemporaneous blog postings, like this one, that described what was going on during that time. The key lessons -- transparency to help create a common understanding of the financial situation, creation of live and electronic forums to encourage participation, demonstrating respect for the people and ideas presented, and a clear explanation for the decisions reached -- are discussed in more detail in this posting by PBS's Paul Solman (starting at minute 1:45 in the video).

As our merry band of senior executives and clinical leaders continued our course in Lean philosophy and techniques today, we were reminded of the foundational power of the 5S, often called the first step in workplace improvement: Sort, set in order, shine, standardize, sustain. The storyboards above give some examples of the applications of these from clinical locations at BIDMC as we have proceeded with BIDMC SPIRIT over the last several months. As you look at them, they seem common-sensical and easy, but it takes practice and training to notice the opportunities and implement this kind of improvement.